Cautious backing for rise in number of physician associates

Emily Chesterton died after a blood clot was missed in two appointments with a physician associate she believed was a GP

Medical leaders support a planned increase in the number of physician associates (PA) in the NHS, but they warn guidelines must be clear.

The Academy of Medical Royal Colleges welcomed more PAs but the BMA voiced concerns that a new law risked blurring the line between PAs and doctors.

PAs assist healthcare teams and can conduct physical examinations and develop treatment plans.

Two families whose relatives were seen by PAs say the role needs more clarity.

The British Medical Association (BMA) said it was concerned that a new law allowing the General Medical Council (GMC) to regulate PAs could confuse doctor and PA roles and could risk patient safety.

The Academy of Medical Royal Colleges said it welcomes PA numbers rising but it was "vital" that there are clear guidelines on how they are deployed.

The NHS has 3,286 PAs, who assist healthcare teams but are not authorised to prescribe. They can order ultrasound or MRI scans but not scans involving ionising radiation, eg X-rays or CT scans, or nuclear medicine scans.

Both PAs and anaesthetic associates (AA) qualify after a part-funded two-year master's degree. They usually need a bioscience-related first degree, but that is not a pre-requisite.

Their role includes taking medical histories, conducting physical examinations and developing treatment plans.

Like PAs, AAs are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor.

The government says it wants to increase the number of PAs to 10,000 by 2036 to 2037 and the number of AAs to 2,000 over the same period.

'Breathless, light-headed and difficulty walking'

Emily Chesterton, from Salford, died aged 30 after a blood clot was missed in two appointments with a PA she believed was a GP.

She had called her GP practice complaining of pain in her calf, which had become hard. She then saw a PA in person, who recommended paracetamol.

But she got worse.

Emily's mother Marion Chesterton told the BBC: "She was breathless, light-headed and she had difficulty walking.

"In the second appointment, the PA diagnosed her with a calf sprain, long-Covid and anxiety."

But the PA did not examine Emily's calves, and did not make it clear that she was not a doctor, Marion said.

Emily had a blood clot in her left leg which led to her dying of a pulmonary embolism, which is when a blood clot gets stuck in an artery in the lung.

The coroner's conclusion was that Emily "should have been immediately referred to a hospital emergency unit". If she had been seen, it is likely that she would have survived.

Emily's GP surgery, The Vale Practice in London, told the BBC that it was "deeply saddened" by her death and now only provides appointments with GPs, nurses and pharmacists after a "thorough" review.

It added that staff have been told to ensure that "a patient understands their role at the start of each appointment".

Ben Peters' case was not one of misdiagnosis and all correct procedures were followed, but it did highlight that a patient under the care of a PA could be discharged without being seen in person by a doctor.

Ben, from Cheadle, went to the emergency department at Manchester Royal Infirmary on 11 November 2022, with chest pain and shortness of breath. He was also severely vomiting.

The 25-year-old was looked at by a PA, who ordered an ECG and all other appropriate tests, according to the Manchester Foundation Trust (MFT)'s letter to the coroner.

They also said that the PA was being supervised by an experienced consultant physician in acute medicine.

The PA took an X-ray of Ben's chest, which appeared normal, and he was discharged with a panic attack and gastric inflammation diagnosis after a discussion between the PA and the duty consultant, who also prescribed medication.

The consultant did not see Ben in person.

Ben's father Steve found him dead the following morning in their home. The inquest found that Ben suffered from a very rare condition called an acute aortic dissection, a tear of the body's main artery.

The coroner's report expressed concern over Ben not being seen to in person by a doctor

Ben's family have now all been screened for the same condition from which he died. Steve was found to have a faulty aortic valve and enlarged aorta, which resulted in surgery in 2023.

"Ben's chest pains were put down as anxiety so he was sent home with tablets to calm him down," Ben's mother Anna Peters told the BBC.

The hospital trust told the coroner that an acute aortic dissection is an "extremely rare condition" and none of the investigations performed on Ben revealed it.

The trust also said that Ben's case was reviewed by several emergency medicine, acute medicine and cardiology consultants, who agreed on the approach that was taken.

There had been no misdiagnosis, it told the BBC, and had Ben been seen in person by a doctor, this would sadly not have made any difference to the outcome.

The coroner's report said Ben's death was a "matter of concern" that despite his reported symptoms, age and "extensive" family history of cardiac problems, he was discharged without being examined in person by a doctor.

But the report acknowledged that all appropriate procedures were followed and investigated, and that neither the hospital or the PA were responsible for Ben's death.

Ben's family have all been screened for underlying conditions

In response to a BBC Freedom of Information request, NHS England said that as of 30 September 2023 there were 3,286 PAs in primary and secondary care in England and 76 AAs in secondary care.

An NHS England spokesperson told the BBC that PAs "play an important role in supporting the NHS".

Adam Skeen started working as a PA in 2021 before going to medical school. He is a BMA representative, but not speaking on behalf of them.

He said his day-to-day tasks were "difficult for the untrained eye to distinguish from that of the team of doctors" with whom he worked.

"Physician associates are not doctors and have not completed a medical degree. Patients deserve to be treated by those with more experience and training.

"For patients, because these tasks look like those of a doctor, it may have been difficult for them to appreciate that I was not a doctor. This is worrying."

Now as a medical student, Adam said his training is distinctly different.

Some doctors argue that, when used correctly, PAs can be largely beneficial to healthcare settings.

Prof David Strain, a consultant based in Exeter who chairs the BMA's board of science, said that PAs' basic training puts them in a good position to do rudimentary clinical examinations, which eases the load on wards.

However, Prof Strain said that he was "incredibly worried about missed diagnoses" because of a lack of training.

The Faculty of Physician Associates makes it clear that PAs "are not doctors" and "do not replace medical roles".

What will regulation mean?

On 26 February, the regulation, called the Anaesthesia Associates and Physician Associates Order 2024, was debated in the House of Lords.

Both houses of Parliament have approved the new law, meaning regulation can be made into law.

Once it begins, PAs and AAs will go on the register of the GMC, which will oversee their work.

The GMC says this will mean it can set conditions for PA and AA course providers to meet to ensure adequate training.

Regulation will also mean they will have to go through a revalidation, which the GMC uses to make sure those on the register remain fit to practise.

The GMC and Royal College of Physicians (RCP) make it clear that there needs to be additional education, a defined scope of practice and guidance for PAs and AAs, which they hope regulation will bring.

Currently there is a curriculum for them, but no overseeing regulator.

Donya Mighty has been working as a PA since 2018, while studying to become a doctor herself. She says the key benefit of the role is continuity of care for patients.

Donya is in favour of the regulation but says her colleagues would "welcome further clarity on their scope for progression."

Her sentiment is echoed by Adam and Prof Strain who say they support regulation, but not by the GMC, as it "blurs the lines between doctors and PAs".

An anaesthetics trainee in the Midlands told the BBC he was concerned that a PA in his area was added to the registrars' list.

"If you haven't been to medical school and studied the anatomy, how can you be giving informed advice?" the trainee added, calling the move "dangerous".

Ben's family wants the distinction between physician associates and doctors to be clearer

'Patients deserve to know who they're seeing'

Ben's family is now trying to raise awareness of aortic dissections and underlying conditions by working with charity Cardiac Risk in the Young.

The family told the BBC they want the distinction between doctors and PAs to be clearer for patients.

Emily's family is also trying to raise awareness and believe "all patients should have the right to know who is treating them and have the choice to see a fully-qualified doctor".

Marion, Emily's mum, said: "If I had my time over, I would have taken her straight to A&E. That is the biggest regret of my life.

"My advice to anyone is always ask who you are seeing."